WASHINGTON, March 7 -- The Senate Veterans' Affairs Committee issued the following testimony by Keith E. Harman, commander-in-chief of the Veterans of Foreign Wars of the U.S., at a joint hearing with the House Veterans' Affairs Committee to examine the legislative presentation of the Veterans of Foreign Wars of the U.S.:

"Chairmen Isakson and Roe, Ranking Members Tester and Walz, Members of the Senate and House Committees on Veterans' Affairs, it is my honor to represent the nearly 1.7 million members of the Veterans of Foreign Wars of the United States (VFW) and its Auxiliary. It is a great pleasure to advocate on behalf of our nation's veterans, military service members, and their families.

"Sequestration: As the national commander, I have had the privilege of visiting and speaking with our service members, veterans, and their families throughout the world. In my travels I have seen first-hand the impact of sequestration and have made ending sequestration my number one priority.

"The VFW applauds the recent bipartisan budget agreement which will alleviate the impact of sequestration on the benefits and services for service members, veterans and their families. The VFW is pleased that the budget agreement includes $4 billion to address urgent Department of Veterans Affairs (VA) infrastructure needs and increases the non-defense discretionary caps, which would enable VA to begin implementing its seamless Department of Defense and VA electronic health care record, fund the recent executive order to reduce the rate of suicide among recently discharged veterans, and improve access to health care for veterans.

"However, the bipartisan budget deal simply delays sequestration for two years instead of completely repealing the sequestration spending caps which were created in 2011 when the Joint Select Committee on Deficit Reduction failed to agree on $1.5 trillion in deficit reduction. Sequestration has taken a massive toll on programs critical to our military and veterans.

"Our armed services face difficulties with reduced readiness, delayed maintenance and modernization, and cuts to quality of life programs. The lack of a timely, fully-funded defense budget hinders DOD's ability to properly plan for our country's defense, defeat our enemies abroad, and execute their most solemn duty -- to bring home our missing.

"VA has requested that funding for the Veterans Choice Program be moved from mandatory to discretionary spending and merged with its medical services account. Given that Choice Program spending has risen to nearly $5 billion and the estimated continued increase of demand for VA health care, including community care, will continue to increase and will require future adjustments to sequestration spending caps. VA's commendable decision to adopt the same electronic health care record as DOD will also increase demand for funding above current spending caps. The VFW will not tolerate cuts to veterans' programs or services to pay for such needs.

"Compounding the problem is the increased reliance by Congress on continuing resolutions (CRs) to fund the government. For DOD, this means instability and uncertainty into the funding process by limiting long-term decision making, canceled training, penalties on contracts, delayed maintenance on weapons systems, lack of equipment, cuts to quality of life programs, longer deployments, wear on materials, and an overall decreased readiness status.

"The resources VA is given to care for our nation's veterans has increased in past years, but outdated and arbitrary budget caps on federal discretionary spending have prevented budget increases from keeping pace with the growing demand on the VA health care system. Budget caps have forced VA to request less resources than needed to accomplish its mission and required Congress to provide VA less resources than it has requested, which hinders VA's ability to meet its obligation to our nation's veterans.

"The good news is that the Bipartisan Budget Act of 2018 establishes a Joint Select Committee on Budget and Appropriations Reform, which is tasked with providing recommendations and legislative language that will significantly reform the budget and appropriations process. The VFW urges the members of these committees who have been appointed to this super committee to work with members from both chambers and different ideological and political beliefs in order to strike an agreement on common sense budget reforms. The VFW stands ready to assist this super committee in succeeding where the previous one failed. Service members, veterans, and their families are counting on you do the right thing and repeal sequestration once and for all.

"Fiscal Year 2019 Budget Request: The VFW, in partnership with the Independent Budget (IB), produces annual budget recommendations for each of VA's major funding accounts and compares them to the Administration's request. More complete details on the IB recommendations can be found at: www.independentbudget.org/

"The VFW was pleased to hear Secretary of Veterans Affairs David Shulkin's decision to have the Department adopt the same electronic health care record (EHR) system as the Department of Defense (DOD), putting an end to the saga of not being able to efficiently integrate military treatment records into a veteran's treatment plan. This plan will greatly improve the delivery of care to ill and injured veterans, and ensure truly integrated care as service members transition from DOD to VA care.

"While improvements to information technology (IT) systems are an important part of VA's mission, the cost of doing so cannot come at the expense of health care veterans have earned. We call on Congress to balance the needs of an improved VA with the need to ensure high quality health care is provided to all eligible veterans. In VA's fiscal year (FY) 2019 budget request, VA states it will transfer $782 million from its FY 2018 medical care and Office of IT appropriations to its EHR modernization program. The VFW supports an integrated VA-DOD EHR, but we do not endorse taking critical funds away from health care to pay for it.

"The VFW calls on Congress to allocate the nearly $800 millionVA needs in FY 2018 for EHR modernization from the additional fiscal year 2018 discretionary non-defense appropriations included in the recent bipartisan budget deal. Doing so would ensure VA can begin its work to provide a truly seamless transition for our service members and our veterans.

"VA's Legislative Recommendations: Each year VA provides a list of legislative priorities in its annual budget proposal meant to provide new or extend existing authorities. Most of these proposed priorities make sense, like extending the grants for transportation of highly rural veterans, adjusting pay caps for registered nurses so VA can hire and retain high-quality nurses, provide legal services for homeless veterans, authorize VA to pay for medical foster care, authorize VA doctors to practice across state lines, extend VA's authority to operate the Manila VA Regional Office, authorize VA to inscribe veterans' headstones to honor their spouses or dependent child, and close the loophole which allows flight schools to charge exorbitant fees for flight training.

"Others recommendations the VFW opposes. VA is currently authorized to offset the cost of providing non-service-connected care to veterans by billing their other health insurance, which includes employer sponsored insurance and other private health care insurance coverage. VA collects nearly $3.3 billion in medical care collections a year. However, the Congressional Budget Office has consistently found that VA fails to collect as much as it should from billing private health insurance. The VFW supports several initiatives to increase VA medical care collection, such as requiring health care networks to consider VA an authorized provider so VA can receive higher reimbursement rates. The VFW also supports authorizing VA to bill Medicare and TRICARE for non-service-connected care delivered at VA medical facilities. However, we oppose proposals to eliminate incentives for sharing other health care insurance information or punishing veterans who may not know their health insurance information has changed.

"The VFW also continues to oppose efforts to nickel and dime veterans by reducing their annual cost-of-living adjustments. Veterans should not be asked to give up one benefit for another nor should veterans be required to forgo their benefits to expand benefits to other veterans.

"Community Care: VFW members overwhelmingly agree that veterans must have access to community care doctors when VA care is not readily available. However, Congress and VA must improve the current systems and processes to integrate private sector providers and other public health care systems into the veterans' health care system to ensure veterans have a seamless experience when accessing the care they need, regardless if it is at VA medical facilities or through private sector doctors.

"To bridge the gap between thousands of veterans waiting too long for care, and the integrated system veterans deserve, Congress established the Veterans Choice Program. The Choice Program had a rough start, but it has made significant progress and has helped nearly two million veterans receive needed health care. However, the current program continues to face several challenges and must be improved before it is made permanent.

"In the past three years, the VFW has assisted hundreds of veterans who faced delays receiving care through the Choice Program and has surveyed veterans specifically on their experience using VA community care and the Choice Program. Through this work, the VFW identified and worked with Congress and VA to address more than 15 issues with the program. For example, veterans continue to receive bills from private sector doctors who were unable to receive timely payment from VA because of complicated rules determining when VA was able to pay and when it was required to serve as a secondary payer. Veterans should never be billed for care that VA is responsible for paying. The VFW thanks these committees for eliminating the secondary payer requirements and making other legislative changes the VFW has identified to improve the Choice Program.

"The VFW also commends VA and third party administers for their willingness to work with us to address issues veterans encounter when obtaining private sector care. VA has made more than 70 modifications to the Choice Program's contract to address many of the pitfalls that have plagued the program, such as allowing the contractors to conduct outbound calls when they have the proper authorization to begin the scheduling process.

"However, the Choice Program is only a stopgap, and while it has been extended twice in the past year, it must be replaced with a permanent and improved community care program. For the VFW, any future community care program must assure the decision of when and where veterans receive their care is decided by veterans and their doctors, consolidate all community care programs into one, and make the program discretionary instead of mandatory spending.

"The VA health care system delivers high-quality care and has consistently outperformed private sector health care systems in independent assessments. The VFW's numerous health care surveys have also validated that veterans who use VA health care are satisfied with the care they receive. In fact, our latest survey found that 77 percent of veterans report being at least somewhat satisfied with their VA health care experience. When asked why they turn to VA for their health care needs, veterans reported that VA delivers high-quality care which is tailored to their unique needs, and because VA health care is an earned benefit.

"VA has made significant strides since the access crisis erupted in 2014 when whistleblowers across the country exposed how long veterans were waiting for the care they have earned and deserve. However, VA still has a lot of work to do to ensure all veterans have timely access to high-quality and veteran-centric care. Veterans deserve reduced wait times and shorter commutes to their medical appointments. This means turning to community care when needed, but it also means improving VA's ability to provide direct care.

"That is why the VFW supports S. 2193, the Caring for Our Veterans Act of 2017, which would build on current community care programs by putting an end to arbitrary standards for when veterans may receive community care and consolidating multiple disparate community care programs into one. It would also eliminate confusion over when and how veterans can access community care doctors, and ensure VA remains the coordinator of care for veterans regardless of where the care is delivered.

"Additionally, S. 2193 would strengthen the VA health care system and expand its ability to provide direct care to our nation's veterans, while preserving VA foundational services which cannot be duplicated in the private sector. It would expand and improve VA's graduate medical education and loan repayment programs to ensure VA is able to recruit and retain high-quality health care professionals. It also includes much-needed supplemental appropriations to expand and improve VA's capital infrastructure, and authorizes VA health care professionals to practice telemedicine across state lines to ensure veterans, particularly those in rural settings, have convenient access to virtual health care.

"The VFW calls on Congress to swiftly pass of S. 2193, the Caring for Our Veterans Act of 2017.

"Telemedicine: With geographic distance remaining a significant barrier to care for many veterans, the use of telemedicine technology has emerged as a highly effective method of providing veterans with timely and convenient care. The recent actions by Secretary Shulkin to expand the use of technology are laudable, but must be backed with legislative action. The VFW hears from VA providers who fear losing their licenses if they practice medicine across state lines. Congress must pass S. 925, the VETS Act, which would authorize veterans to receive the telehealth care they need regardless of where they are located.

"Veterans who live in highly rural areas, have little to no internet access, and have long driving distances, must be the focus group for telemedicine expansion. Partnering with community organizations, including veterans service organizations (VSO), would be an opportunity to increase access and further reduce barriers. The VFW encourages both Congress and the VA to identify partners and reduce regulatory burdens to identify community locations where veterans could use telemedicine technology to access high-quality health care.

"Caregivers: Family caregivers who choose to provide in-home care to veterans who were severely disabled in the line of duty truly epitomize the concept of selfless service. They choose to put their lives and careers on hold, often accepting great emotional and financial burdens. They do so recognizing that their loved ones benefit greatly by receiving care in their homes, as opposed to institutional settings. The VFW strongly believes the contributions of family caregivers cannot be overstated, and our nation owes them the support they need and deserve. Unfortunately, the Program of Comprehensive Assistance for Family Caregivers is limited to the caregivers of post-9/11 veterans. Severely wounded and ill veterans of all conflicts have made incredible sacrifices, and all family members who care for them are equally deserving of our recognition and support. The fact that caregivers of previous era veterans are currently excluded from the full complement of program benefits implies that their service and sacrifices are not as significant, and we strongly believe this is wrong.

"The VFW commends the Senate Committee on Veterans' Affairs for its efforts to correct this inequity through the Caring for our Veterans Act of 2017, which would expand the caregivers program to wounded veterans of all eras. The VFW frequently hears member feedback regarding eligibility for this important program. Their message is clear: veterans of all eras deserve caregiver benefits. As an intergenerational VSO that traces its roots to the Spanish American War, this is not surprising.

"Our members are combat veterans from World War II, the Korean War, the Vietnam War, the Gulf War, and various other conflicts, in addition to more than 300,000 veterans from the wars in Iraq and Afghanistan. They rightly see no justifiable reason to exclude otherwise deserving veterans from program eligibility simply based on the era in which they served.

"Expanding caregiver benefits is also the more financially responsible decision. Time and time again it is found that providing benefits to caregivers decreases spending. Caregivers are more cost efficient than nursing homes and assisted living facilities. Congress must pass S. 2193 to give veterans of all eras the opportunity to live at home with their loved ones as long as possible.

"Mental Health and Suicide: In September 2016, the VFW launched a Mental Wellness Campaign to change the narrative in which America discusses mental health. We teamed with Give an Hour providers, One Mind researchers, the peer-to-peer group PatientsLikeMe, the family caregiver-focused Elizabeth Dole Foundation, the nation's largest pharmacy Walgreens, and the Department of Veterans Affairs to promote mental health awareness, to dispel misconceptions about seeking help, and to connect more veterans with lifesaving resources. The goal of the continuous VFW campaign is to destigmatize mental health, teach our local communities how to identify mental distress and what local resources are available to those struggling to cope. To do this, VFW Posts and our partners have held mental wellness workshops in every state from Virginia to California, to spread awareness of VA's mental health care services, as well as teach how to properly identify a fellow veteran in distress. VFW members talked to their fellow veterans about the Campaign to Change Direction and five warning signs of mental distress -- personality change, agitation, withdrawal, poor self-care and hopelessness.

"The VFW has worked tirelessly these past few years to get people talking about mental health, to notice when somebody else may be in a mental health crisis, and to finally start getting rid of the stigmas that our society has held against seeking mental health care. The more we talk about it, the more we educate people about it, the more we address the actualities of mental health and suicide -- the more comfortable society and individuals suffering are going to become with accessing the care they need. Our citizens know the signs of seeing somebody experiencing a heart attack. Now it is time for people to recognize the five signs of mental distress, and to know it is cannot be medically ignored.

"The VFW knows that outreach is critical to ensuring veterans are able to access the mental health care they need. That is why the VFW looks forward to working with VA and DOD to implement the recent executive order which requires VA, DOD, and the Department of Homeland Security to reduce the rate of suicide among recently discharged veterans.

"In August 2016, VA released the nation's largest analysis of veteran suicide ever conducted. While this data is incredibly critical in addressing and hopefully ending veteran suicide, VA still needs more analysis of the available data. From the data released in 2016, VA found that of the average 20 veterans who die by suicide each day, only six of those veterans used VA care within a year of their death. VA, VSOs, the Senate and the House need to know more about the 14 veterans not actively enrolled in VA. The VFW urges Congress to commission a study on the demographics, illnesses, socioeconomic status and military discharges of those veterans. There are questions that need to be answered in order to properly address this unfortunate problem. Did those 14 use private sector care? Were they eligible to use VA? Were they among the many who were discharged without due process for untreated or undiagnosed mental health disorders related to sexual trauma or combat? If we are going to honestly combat veteran suicide, we must know more about the 14 veterans who die each day without using VA.

"Particularly concerning is that the risk for suicide in the female veteran population is 2.4 times higher when compared to their civilian counterparts. While these numbers are alarming, they are also incredibly insightful for purposes of helping Congress and VA work toward eliminating the current plague of suicide in the veteran population. Since 2001, the rate of suicide among women veterans who use VA services increased by 4.6 percent, yet for women veterans who have not used VA care their rate of suicide nearly doubled, which is unacceptable.

"Women veterans seeking mental health treatment often face unique barriers or challenges. While people of different genders struggle with mental health for the same reasons, mental health conditions linked to sexual violence, such as post-traumatic stress disorder (PTSD), affects women at a much higher ratios than men. As the population of women veterans continues to rise, it is of the utmost importance that VA continues to prioritize their often overlooked health care needs.

"Passage of S. 925, the VETS Act, would also be invaluable in decreasing risk of suicide for women veterans who need group therapy for mental health linked to sexual violence. In areas where there may not be enough women to get a group therapy session started, telemental health provides the opportunity to participate in group therapy without having to be assigned to the same VA medical facility or co-located. The VFW also urges VA to do two things. First, begin taking sex more seriously into consideration before prescribing psychopharmaceutical treatments. Medications have different effects on people of different sexes. The VFW asks VA to serve as a good example in prioritizing this factor. Second, VA must continue training mental health providers and employees on proper treatments and care of patients with PTSD due to sexual trauma.

"As technology continues to improve, VA must continue researching new ways to reach those in need of mental health care. Over time, VA has excelled at making sure to offer user-friendly apps, such as the PTSD Coach, for veterans to conveniently access in their times of need. Yet apps are not the avenue of prevention or intervention all veterans prefer. Congress and VA must continue to fund studies to understand how technology can be used to identify and assist veterans experiencing mental health crises and/or suicidal ideations. For example, linguistic psychologists in academia at schools such as the Massachusetts Institute of Technology have found there are words used at increased frequency when individuals are experiencing suicidal ideations and mental health crises. These words are not the "cliche" words taught to us in the military or at local high schools. If VA providers or family members knew which words to monitor, they would be able to intervene before it is too late.

"In order to lower the number of suicide attempts and to hopefully eliminate veteran suicide altogether, VA must increase access to competent mental health care that is individualized to the patient. The VFW also looks forward to continuing to work with VA as it implements the recent executive order to assure clinical access to all veterans during their first year of separating from the military.

"The VFW continues to hear from veterans that VA needs to hire more mental health care providers. This shortage of providers has been continually highlighted by the Government Accountability Office and VA Office of Inspector General (OIG) reports in past years. Specifically, the OIG's yearly determination of occupational staffing shortages across the VA health care system has placed psychologists among the top five VA health care professions staffing shortages. This is due in large part to a general lack of mental health care professionals in the United States. Congress must ensure VA has the authorities and resources it needs to compete with private sector hospitals for high-quality mental health care providers.

"Staff shortages often results in veterans who seek care from VA not being able to receive the lifesaving care they need in a timely manner or being denied care altogether. This is why the VFW asks Congress and VA to expand peer-to-peer support for veterans wanting to volunteer. In instances where VA is not able to provide immediate assistance, or a veteran requesting assistance does not meet the protocol for needing inpatient care, VA could utilize these volunteers. It is common practice in the private sector for hospitals and medical facilities to have volunteers on call to assist patients, such as sexual trauma victims who check into emergency rooms. If VA trains more peer-to-peer support specialists, VA medical centers would be able to have scheduled, on call veterans to assist others in mental health crises. Peer-to-peer support has been proven time and time again to successfully help veterans in need.

"For veterans in crisis, it is incredibly important for them to have the ability to use the Veterans Crisis Line (VCL). The VFW applauds VA on expanding the new crisis line in Topeka, Ka. Access is notably increasing despite the crisis line receiving more calls on a daily basis. The VFW believes VA has been successful in performing outreach to educate veterans about the crisis line. The VFW also lauds VA for updating the phone systems at all medical centers and certain outpatient clinics so veterans in crisis are no longer required to hang up the phone and call the VCL. Most VA facilities now offer the opportunity to "Press 7" to reach the crisis line. Still, the VFW believes there is room for improvement and that all VA medical centers, outpatient clinics and Vet Centers must have this option. The expansion has so far shown a positive impact. We ask Congress to provide VA the resources it needs to ensure all its medical facilities can provide this incredibly important feature.

"According to DOD's Defense and Veterans Brain Injury Center, more than 375,230 service members were diagnosed with traumatic brain injury (TBI) between 2000 and 2017. VA has made significant progress in diagnosing and treating TBI-related conditions since the start of the wars in Iraq and Afghanistan. VA has polytrauma rehabilitation sites across the country; including six Polytrauma Rehabilitation Centers, 23 Polytrauma Network Sites and 87 Polytrauma Support Clinic Teams. VA must continue to expand its sites and services to ensure veterans who suffer from conditions associated with TBI are afforded the specialized care they need. Specifically, the VFW urges VA to expand its Individualized Rehabilitation and Community Reintegration Plan of Care to ensure all veterans with TBI have an individualized plan to maximize their independence and restore physical and cognitive functions.

"Additionally, VA and Congress must continue to commission research on the effects TBI has on cognitive and behavioral functions, and develop treatment programs for any and all research that shows promise in improving health outcomes and quality of life for affected veterans. The VFW also believes veterans must not only receive health care for conditions that are found to be related to blast injuries, but VA should establish these conditions as presumptive for compensation. Many service members go untreated while in service, so there is no medical evidence of the condition in their military health records. This is why the VFW urges Congress and VA to improve research pertaining to TBI screening methods, diagnostic tools, and to make conditions associated with blast injuries presumptive.

"Medical Cannabis and Integrative Medicine: VA mental health care is making a positive impact on those who use it, but there is still room for improvement. More studies must be conducted to find more innovative ways to treat mental health conditions. VA has conducted research pertaining to areas such as service animals, but other integrative therapies such as medical cannabis have been reported as being effective and must be explored.

"In the past several years PTSD and TBI have been thrust into the forefront of the medical community and general public in large part due to suicides and overmedication of veterans. Medical cannabis is currently legal in 30 states and the District of Columbia. Many of these states have conducted research for mental health, chronic pain and oncology at the state level. States that have legalized medical cannabis have also seen a 15-35 percent decrease in opioid overdose and abuse. There is currently substantial evidence from a comprehensive study by the National Academy of Sciences and the National Academic Press which concludes cannabinoids are effective for treating chronic pain, chemotherapy-induced nausea and vomiting, sleep disturbances related to obstructive sleep apnea, multiple sclerosis spasticity symptoms, and fibromyalgia -- all of which are prevalent in the veteran population.

"In April 2016, the Drug Enforcement Administration approved a study on the effect of medical marijuana on PTSD, which was intended to be the first federally funded, randomized and controlled research for PTSD in the United States. That study has not gone as planned for multiple reasons, however, such as restrictions placed on possible study participants and unusable marijuana shipments from the only federally-approved grower in the United States.

"The VFW urges Congress and VA to conduct a federally-funded study with veteran participants for medical cannabis. This study should have a focus on participants who have PTSD, but should most definitely include veteran participants who are VA patients for chronic pain and oncology.

"The VFW understands that certain veterans are uninterested or do not believe traditional, empirically proven methods will work for them. To address this issue, VA must partner with private organizations and groups to offer veterans the opportunity to join in alternative and non-traditional therapy options. Psychosomatics and the placebo effect are real. The VFW believes veterans should have the opportunity to participate in integrated therapies that work for them. To do so, VA must partner with organizations that provide complementary and integrated medicine, which has been proven to work non-pharmaceutical alternative to opioid therapy.

"Women's Health Care: VA reports that nearly 492,000 women veterans used the VA health care system in fiscal year 2017, which was a nearly 150 percent increase since fiscal year 2003. VA has worked to improve the gender-specific care for this population of veterans, but more work needs to be done. In 2016, the VFW conducted a survey of nearly 2,000 women veterans as a way to identify the most important issues they are facing in VA. Over the past year we have worked with VA and Congress to address outreach, which is a key recommendation from our report, but other issues still need to be addressed.

"According to VA, the majority of women veterans were assigned to Designated Women's Health Primary Care Providers (DWHP). VA and its Center for Women Veterans have worked to increase those numbers, and the VFW asks Congress to provide VA with the tools they need to continue expanding outreach for knowledge of and access to providers with necessary gender-specific specializations. Other VFW surveys have found that women veterans overwhelmingly prefer to receive their health care from women primary care providers, and are more likely to be satisfied with their VA health care experience when they receive care from women providers. That is why the VFW has urged VA to allow women veterans to choose the gender of their provider when enrolling in health care.

"While the DWHP program is expanding and providing above-satisfactory care to patients, the VFW understands there is still a need for trained gynecologists within VA. Gynecology is sex-specific care that has traditionally been understaffed at VA medical centers across the country. While some providers are able to provide certain procedures that gynecologists specialize in and are able to treat, it is important to increase the number of doctors trained in the specialization of gynecology.

"Some studies have found that women who deployed to combat may have higher rates of abnormal pap smears. As time goes on, more studies are starting to reveal what researchers believe to be higher rates of infertility and complications during pregnancy for female combat veterans as well. With this in mind, the VFW urges Congress to demand a thorough research study by VA to evaluate fertility, infertility, and reproductive health issues for women veterans who have deployed to combat zones during the Gulf War.

"For women veterans who rely on VA for postnatal care, the VFW urges Congress to extend the number of days which newborn care is covered by VA. Typically, in private sector health care, a new mother has a month to enroll her newborn child into an insurance program. Currently, VA only covers newborn care for only seven days. One week of coverage is not enough to provide coverage if anything goes wrong -- even in the not uncommon instance of false-positive testing -- nor is it enough to ease the new mother of unnecessary stress. Congress must pass H.R. 907 or S. 970, the Newborn Care Improvement Act, which would ensure new mothers have sufficient time to transfer their newborn to other forms of health coverage.

"The VFW applauds VA and Congress for their work to provide more access to gender-specific health care providers for women veterans. While overall progress has been made, gender-specific mental health care is still lacking. In VFW surveys, women veterans have voiced concerns over what they view as a lack of gender-specific training for mental health care providers. Congress and VA must work to ensure every VA medical center has mental health care providers who are well trained in conditions such as postpartum depression and conditions that stem from menopause or sexual trauma.

"Peer-to-peer support has proven time and again to be invaluable to veterans and VA. This is why the VFW advocates so strongly for the constant expansion of peer-to-peer support programs. The VFW urges Congress to pass S. 2402 or H.R. 4635, the Women Veterans Peer Counseling Enhancement Act, would greatly expand these programs for women veterans, providing them more peer and gender-based one-on-one assistance from others to whom they can relate and connect. This is extremely crucial in instances where a women may suffer from mental health conditions, but especially in instances where a female veteran is on the verge of homelessness. In our survey, 72 women reported being homeless or at risk of becoming homeless. Of those women, 38 percent reported having children. These women face unique barriers to overcoming homelessness, and frequently commented on the lack of people who actually understand those barriers. By providing peer-to-peer support for women with others who have gone through the same hardships, VA would provide a level of understanding and trust they desperately need.

"Women service members and veterans have also been found to be at increased risk for eating disorders, which have serious consequences for both physical and psychological health as well as high mortality rates. Some of the risk factors which contribute to women veterans struggling with eating disorders include military sexual trauma and combat exposure. As VA continues toward meeting the demands and needs of women veterans, it is important VA establish a comprehensive program for treatment of eating disorders. The VFW urges Congress and VA to establish a program that is easily accessible for treatment.

"Women Veterans Outreach: The VFW applauds VA'sCenter for Women Veterans and their initiative to expand their efforts in recognition and outreach to women veterans. It is disheartening, however, for the VFW to hear time and again from VFW members going to VA appointments that employees confuse them for spouses or caregivers, or even challenge their veteran status. Veterans of all genders, races and creeds have honorably served our country. VA must properly train its workforce to treat women veterans with the respect and dignity they have earned and deserve. The mindset should be to treat every customer as a veteran first.

"The VFW has noticed a much lower utilization and awareness of benefits among older women veterans compared to their younger counterparts. In one of the VFW's surveys, we found older women veterans were less likely to report receiving disability compensation, but equally as likely to have been injured or made ill as a result of their military service. Similarly, older veterans were less likely to report that they use VA health care, but equally as likely to report being eligible for VA health care than their younger counterparts. We were also concerned that several respondents who reported being 55 years old or older believed they did not rate the same benefits as their male counterparts, which is an egregious misperception that must be addressed.

"No veteran should be left to wonder what, if any, benefits they are eligible to receive. Furthermore, it must be clear that women veterans have earned the exact same benefits as their male counterparts. That is why the VFW urges Congress and VA to continue improving outreach to women veterans and conduct targeted outreach to older women veterans to ensure they are aware of all the benefits and services VA provides.

"Preventive Medicine & Services: As the result of a recent survey, the VFW learned in one of its surveys that VA is not required to comply with federal health program requirements to provide cost-free preventive care and medications to beneficiaries. The VA formulary currently carries all pharmaceuticals deemed preventive by the U.S. Preventive Services Task Force. However, VA is exempt from requirements to provide preventive care and services without cost shares.

"Cost is a significant barrier for veterans who use VA health care, whom have been found to have lower income on average than veterans who do not use VA health care. There are currently 11 categories of preventive medications found to be effective by the U.S. Preventive Services Task Force, such as prescribing aspirin to lower the risk of cardiovascular disease. Cardiovascular disease is the number one cause of death in the United States and is prevalent among the veterans population. Additionally, folic acid is recommended for pregnant women to prevent neural tube defects. It is unjust to require women veterans to pay for the cost of birth defect prevention medication, or put service-connected veterans with hindbrain TBI patients in need of Vitamin D to prevent bone fractures or Camp Lejeune toxic water survivors in need of breast cancer prevention medicine in a position where they are unable to access potentially lifesaving medications.

"The VFW calls on Congress to swiftly pass S. 1161 or H.R. 1100, the Veterans Preventive Health Coverage Fairness Act, which would eliminate this inequity and ensure veterans have access to lifesaving preventive medicine.

"Appeals Modernization: The VFW applauds Congress for passing the Veterans Appeals Improvement and Modernization Act of 2017, and we look forward to working with VA on the continued implementation of the Rapid Appeals Modernization Program (RAMP). RAMP tests two of the three options under the new appeals modernization process -- Supplemental Claims and Higher Level Review -- which offer veterans an opportunity to resolve their appeals at the regional office level in a practical and non-adversarial manner.

"Two of the most critical aspects of the new appeals framework are the preservation of an appellant's effective date and improved notification letters to claimants, which outlines specific criteria on how VA arrived at its decisions. These major reforms are veteran-centric and ensure that not only can veterans receive timely decisions on their claim actions have the ability to address grievances without forfeiting benefits and veterans are able to make informed decisions.

"While the VFW continues to have reservations regarding the timeliness and accuracy of information shared with VSOs and these committees, we are pleased VA continue to collaborate with the VSO community to ensure RAMP succeeds. VA employees and the VFW's network of accredited claims representatives must continue to partner in educating veterans on how to properly navigate the new appeals framework. VA is now sharing more data with VSOs, which we feel will improve implementation efforts. The VFW has received reports of both grants and denials for our clients through RAMP. With improved denial letters, veterans now have access to more information with which they can better understand how VA arrived at its decisions and more easily navigate the appeals process moving forward.

"With all of this in mind, we are now comfortable with encouraging certain appellants to opt into RAMP, if the circumstances seem beneficial for their claim. We have asked VFW's accredited representatives to evaluate each veteran's claim on a case-by-case basis to determine if their appeal can be resolved by submitting new and relevant evidence (Supplemental Claim) or by having a more experienced VA staffer review the record (Higher Level Review). The VFW has not seen a high level of participation in RAMP to date, as VA started implementation with the oldest claims first. From our clients, we have noticed that many appellants with the oldest claims already had scheduled hearings or were only awaiting a new decision. In February, VA started to offer opt-in notices to veterans with new Notices of Disagreement (NODs) as well. The VFW believes that RAMP may be an advantageous route for new NODs, as they will have no incentive to stay in the legacy appeals framework.

"As the new appeals framework rolls out, the VFW believes that VA will have more work on its hands at every level. The potential influx of supplemental claims, higher level reviews, and appeals on multiple Board of Veterans Appeals (BVA) dockets must be taken into consideration when allocating resources. However, this does not abdicate VA's responsibility to adjudicate legacy appeals from veterans who choose not to opt into the new framework. This is why the VFW calls on Congress and VA to continue to properly resource Veterans Benefits Administration (VBA) and BVA to ensure they are able to timely adjudicate appeals from veterans who remain in the legacy system. The VFW commends VA for being mindful of the increased workload by hiring 95 percent of their authorized staff for the BVA. Additionally, VA must be empowered to manage its workload if the new framework to expected to succeed.

"Disability Compensation and Benefits: For more than 118 years, the VFW has led the charge to improve and protect veterans' benefits and compensation. The VFW's charter compels us to assist and speed the rehabilitation of the nation's veterans and their families. More than a century of executing this duty by way of legislative advocacy and service within the veterans community has made the VFW one of the most powerful and well-respected organizations in the United States. While we appreciate that VA and Congress have generally gone a long way to ensure that veterans' benefits and entitlements are protected, we feel as though it is of utmost importance that more is done to ensure that veterans and their dependents have timely access to those benefits.

"In recent months, the VFW has heard grumblings that VA disability compensation does not encourage "wellness," and erroneous claims that veterans abuse the system. These claims are flat out false, and the VFW will fight back aggressively on this narrative, as we have done since our inception. Critics also point out that disability compensation has grown over the years as a portion of the VA budget. To the VFW, this reflects the true cost of war -- a cost that our nation has never fully recognized when choosing to send our military men and women into harm's way. Our veterans earned these benefits, and the VFW will do everything in its power to ensure that veterans past, present and future receive all of the benefits to which they are entitled.

"Concurrent Receipt & SBP/DIC: Military retirees with 20 or more years of service qualify for retirement pay based on their dedicated service to our nation. These same veterans often times qualify for disability compensation for any injuries that were caused or aggravated by their military service. Prior to 2004, however, military retirees could not receive both retirement pay and disability pay because it was erroneously perceived as a duplication of benefits.

"Since 2004, the VFW has pushed Congress to implement a phase-in of full concurrent receipt for all retirees who are rated 50 percent disabled or greater, which led to the creation of two offsets - the Concurrent Retirement Disability Pay (CRDP) which applies to standard retirees with service-connected disabilities, and Combat-Related Special Compensation (CRSC), which applies to those with combat-related disabilities. Currently, CRDP is automatic for all retirees who serve 20 years or more with a VA rating of 50 percent or greater. However CRSC must be applied for through the branch in which the veteran served, including those who were retired as a result of injuries sustained in combat, but served less than 20 years.

"The VFW has long argued that retired pay and VA service-connected disability compensation are fundamentally different benefits, granted for different reasons. Military retired pay is earned by 20 or more years of service in the United States Armed Forces, or in some circumstances by becoming severely injured as a result of military service. Service-connected disability compensation on the other hand is a benefit meant to supplement a veteran's lost earning potential as a result of the disabilities he or she incurred while in service.

"The VFW has strongly supported an amendments to the National Defense Authorization Act (NDAA) for FY 2018, that would have allowed the receipt of both military retired pay and veterans' disability compensation with respect to any service-connected disability, and would have repealed provisions phasing in the full concurrent receipt of such pay through December 31, 2013. This amendment was based on stand-alone legislation introduced in both the House and Senate by Representative Gus Bilirakis and Senator Dean Heller, respectively.

"Despite broad bipartisan support throughout both chambers, some members of Congress continue falsely believe concurrent is a form of "double dipping." Furthermore, House rules for the NDAA for FY 2018 did not allow for any increases in mandatory spending-- something that the amendment would have required. As a result, after the amendment was introduced it had to be withdrawn.

"In a similar manner, the VFW has urged Congress to eliminate the dollar-for-dollar offset that has prevented surviving spouses from receiving both Survivor Benefit Plan (SBP) payments from the Department of Defense (DOD) and Dependency and Indemnity Payments (DIC) from VA. The VFW sees SBP and DIC as two separate benefits, paid from two separate government agencies for two separate reasons. While the VFW applauds Congress for making Special Survivor Indemnity Allowance permanent, which pays $310 a month to SBP/DIC recipients, the VFW urges Congress to completely repeal this offset.

"The VFW believes that it is critical that ALL disabled retirees, including Chapter 61 retirees and survivors, are able to collect any benefits they are entitled to by way of their sacrifices to this nation, without offset. It is for this reason that we fully support H.R. 303 and its Senate companion, S. 66, the Retired Pay Restoration Act; as well as H.R. 846, the Military Surviving Spouses Equity Act, or S. 339, the Military Widow's Tax Elimination Act of 2017, which would honor the sacrifices of our nation's heroes by ensuring their survivors are able to maintain at least a modest quality of life, without having to unjustly offset their benefits.

"Private Medical Evidence: Veterans should not be required to see a VA doctor in order to validate their private provider's findings. Requiring redundant examinations only costs more money, adds more confusion, and clogs up the system. It is our position that VA must accept evidence from competent, credible physicians, and not force veterans to seek a second opinion from a VA physician. The VFW Calls on Congress to pass S. 706, the Quicker Veterans Benefits Delivery Act of 2017, which would require VA to accept competent, creditable, probative, and relevant private medical evidence in support of a disability compensation claim.

"Hearing and Tinnitus: Veterans who serve is combat are exposed to high level of acoustic trauma. Many pre-service and discharge examinations, particularly for World War II and Korean War veterans, were usually accomplished with the highly inaccurate whispered-voice test which was discontinued many years ago. Many veterans in those cases were not afforded a comprehensive audiological examination upon entrance and/or discharge from military service. In the latest VBA Annual Report updated as of February 2017, the most prevalent service-connected disabilities of all compensation recipients are hearing loss and tinnitus. In 2005 the Institute of Medicine (IOM) released a study that showed nearly all service members are exposed to acoustic trauma at some point during their military service and that many experience hearing loss and/or tinnitus as a result -- sometimes years after service.

"The VFW calls on Congress to pass H.R.4320, the Hear our Heroes Act of 2017, which would expand disability compensation benefits to combat veterans diagnosed hearing loss or tinnitus. Additionally, it directs the Secretary of the VA to amend the Schedule for Rating Disabilities to provide a minimum compensable evaluation for any service connected hearing loss for which a hearing aid is medically indicated.

"Blast Injuries: While the face of war has changed over the past century, the nature of how they are fought has not. Now more than ever, we are seeing service members who are returning from combat with no apparent physical injuries, but sustained injuries as a result of their exposure to explosions. VA has been slow to provide a long-term solution that would address these injuries, despite the overwhelming evidence that suggests service members who are exposed to explosions or sustain concussions often times may experience delayed onset of symptoms and complications ranging from headaches and cognitive impairments, to even more severe neurological complications in the case of soldiers who are directly exposed to blasts. The VFW calls on Congress to pass H.R. 4321, the Blast Exposure Protection Act of 2017, which would amend Title 38 to grant presumption of service connection for conditions associated with blast exposures.

"Burial Benefits: The cost of funeral expenses in the private sector have increased nearly seven-fold since 2001, but VA benefits to cover such costs have failed to keep pace with inflation. The VFW and its IB partners urge Congress to ensure the loved ones of veterans who do not have access to a state or national veterans cemetery within 75 miles are not required to accumulate debt to provide their loved ones a final resting place that honors their sacrifice to our nation.

"The VFW calls on Congress to pass S. 1596, the Burial Rights for America's Veterans' Efforts (BRAVE) Act of 2017, which would increase the funeral and burial benefit for eligible veterans. This important bill would also ensure all three benefits are indexed for inflation.

"Exposures and Other Environmental Hazards: The brave men and women who wear our nation's uniform are asked to serve in the roughest and most dangerous environments on Earth. They unquestioningly serve their country with the utmost faith because they know the freedoms that make this country great are at stake. When they are injured or made ill as a result of such service, a grateful nation owes these selfless warriors the care and benefits their service has earned to cope with such disabilities.

"However, as a multi-generational organization, the VFW cannot advocate for one type of exposure without fighting for others. Research indicates that industrial compounds used for many purposes -- defoliants, radiation from weapons testing, and other items -- all combine to show that veterans from all generations alive today have served in some place where contamination can be found. Their long-term health is jeopardized by such exposure, and Congress must ensure that needed care and benefits are both funded and managed in a nonpartisan manner.

"The VFW stands on its long-time belief that being exposed to contamination does cause health issues. We are appalled at the attempts to force a "pay for" to cover expanding presumptive coverage so as to include those veterans suffering from conditions related to exposures. As such, the VFW calls for regulatory change to streamline the process of adding conditions connected to exposures and the location of those exposures. A federal agency outside of VA and the military, with statutory authority to investigate without interruption, must be identified to conduct research for locations where exposures occur. Those conditions scientifically proven to be connected to the contamination at those sites must be immediately considered presumptively compensable without consideration of cost. If we have the money to go to war, we have the money to provide care for veterans who have borne the battle.

"The VFW commends Senators Moran and Blumenthal for their leadership on the Toxic Exposure Research Act. VA reports that the review of existing research will be complete by 2019. When the Health and Medicine Division of the National Academies of Science, Engineering, and Medicine publishes its finding, Congress must make certain that it funds follow-on research to determine whether the children of veterans exposed to toxic substances experience adverse health conditions that are related to such exposure.

"Blue Water Navy: Currently VA relies on what the Court of Appeals for Veterans Claims has called an "arbitrary and capricious" interpretation of inland waterways, which unjustly denies Vietnam War veterans who served aboard ships in the coastal waters of Vietnam the benefits they deserve. Congress must act immediately and restore the benefits these veterans unjustly lost after regulatory change was made.

"The VFW calls on Congress to pass S. 422 and H.R. 299, the Blue Water Navy Vietnam Veterans Act of 2017, which would expand disability compensation benefits to veterans who were exposed to Agent Orange while serving in the territorial seas of the Republic of Vietnam in support of ground operations during the Vietnam War.

"Burn Pits: The use of open air burn pits in combat zones has caused invisible, but grave health complications for many service members, past and present. Particulate matter, polycyclic aromatic hydrocarbons, volatile organic compounds and dioxins -- the destructive compound found in Agent Orange -- and other harmful materials are all present in burn pits, creating clouds of hazardous chemical compounds that are unavoidable to those in close proximity.

"While the VFW is glad to see that over 130,000 veterans have enrolled in VA's burn pit registry, we are concerned that the results of the National Academies of Science's study on the burn pit registry have not been fully implemented. The findings must be included in forging a path forward for research into conditions caused by exposure to the toxins associated with burn pits. The VFW urges VA and Congress to act swiftly on recommendations from this important study.

"VA must also take measures to improve the Airborne Hazards and Open Burn Pits Registry. For example, a similar registry operated by Burn Pit 360 allows the spouse or next-of-kin of registered veterans to report the cause of death for veterans. VA must add a similar feature to its registry to ensure VA is able to track trends. Other improvements include streamlining the registration process, updating duty locations based on records provided by the Department of Defense, and eliminating technical glitches to ensure veterans are able to register.

"While the VFW is glad to see VA has commissioned independent research on the burn pit registry, more independent research is necessary. That is why the VFW supports establishing a Congressional Directed Medical Research Program (CDMRP) specifically for burn pits. The CDMRP for has shown some progress in identifying causes, effective treatments and biomarkers for Gulf War Illness (GWI), and the VFW is confident a similar program for burn pits will help exposed veterans finally determine whether their exposure to burn pits while deployed is associated with their negative health care outcomes.

"Gulf War Illness: The more than 200,000 Persian Gulf War veterans continue to suffer from conditions that cannot be explained by medical or psychiatric diagnoses, such as chronic widespread pain, cognitive difficulties, unexplained fatigue, and gastrointestinal problems. While the VFW agrees VA's top priority must be to identify effective treatments for GWI, we believe that future research efforts must continue to study all symptoms and conditions associated with GWI. That is why the VFW urges Congress to continue to properly fund the GWI CDMRP.

"The VFW's professionally trained, accredited advocates have encountered numerous difficulties as they work to file claims for GWI. The reality is VA has made the evidence and etiology requirements to be rated for GWI nearly impossible, despite Congress ordering VBA to develop a Disability Benefits Questionnaire (DBQ) that would identify and diagnose this illnesses simply and more easily.

"The cluster of symptoms associated with GWI present themselves in a way that is not always exclusive to persons who have served in our current wars and compensation and pension examiners frequently lack the training to identify the multiple conditions. As such, VA must be compelled to develop claims for possible undiagnosed illnesses first. When GWI is indisputably ruled out, VA should then grant ratings for disabilities individually. However, if the evidence equally proves the veteran could be rated for GWI, VA should be compelled to conclude that the veteran suffers from an undiagnosed illness and should be granted a rating for such.

"This approach is not new and can be found in existing regulations. The "Reasonable Doubt" rule, 38 CFR 3.102, should be applied in all claims for GWI submitted by veterans who file because of qualifying service. VA's application of this regulation, along with the new DBQ, would likely result in veterans suffering from GWI being rated properly the first time. VA has refused to act, so the VFW urges Congress to do so.

"Additionally, veterans who have served in the Southwest Asia Theater of military operations since August 2, 1990, including Operation Iraqi Freedom and Operation New Dawn, are eligible for a Gulf War Registry health exam. This comprehensive exam evaluates exposure and medical history to identify possible long-term health problems that may be related to environmental exposures during military service. While veterans who served in Afghanistan after 2001 are eligible for VA's Airborne Hazards and Open Burn Pit Registry, they are not eligible for the Gulf War Registry health exam. The VFW maintains that Afghanistan veterans served under circumstances similar to those who served in Iraq. That is why we urge VA and Congress to expand eligibility for the Gulf War Registry health exam to veterans of the war in Afghanistan.

"Fort McClellan: From 1943 until its closure in 1999, Fort McClellan, Alabama, was home to thousands of soldiers in the Women's Army Corps, the Army's Military Police Corps, and the Army's Chemical Corps. It was forced to close in 1999 due to investigations by the Alabama Department of Public Health, the Alabama Department of Environmental Management, the Agency for Toxic Substances and Disease Registry, and the U.S. Environmental Protection Agency, which discovered evidence of polychlorinated biphenyls (PCB) contamination in Fort McClellan's neighboring town, Anniston.

"The VFW has heard from several veterans suffering from deteriorating health conditions consistent with PCB exposure that they are unable to obtain the care and benefits they need because their service at Fort McClellan is not considered presumptive exposure to toxic substances. The VFW calls on Congress to commission more research on the health effects associated with exposure to PCBs at Fort McClellan, and to ensure exposed veterans have access to the care and benefits they deserve.

"Camp Lejeune: Thanks to efforts by Senator Burr and members of these committees, VA is authorized to provide no-cost health care to veterans and their families for 15 health care conditions that have been found to be associated with exposure to contaminated water on Camp Lejeune. However, VA expanded presumptive disability compensation benefits for only eight of the 15 conditions. As a result, veterans who served 30 or more days at Camp Lejeune between 1953 and 1987 and have been diagnosed with esophageal cancer, breast cancer, renal toxicity, female infertility, lung cancer, hepatic steatosis, miscarriage, and neurobehavioral effects, are eligible for no-cost VA health care, but still have an uphill battle obtaining disability compensation benefits. The VFW urges Congress and VA to review the medical research linking these conditions to the contaminated water at Camp Lejeune and determine if VA's presumptive list is accurate.